Being Billed Full Amount for Untimely Insurance Claim

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My question involves collection proceedings in the State of: NY

In September of last year I visited a doctor's office. I assumed they billed my insurance and was awaiting a bill for whatever amount remained. I received one 6 months later for the full price of the visit, without insurance deductions or anything mentioning insurance on the invoice. I sent it back to them with my insurance information. I received two more bills for the same amount and no mention of insurance, so I called the doctor's office. They said they would file a claim but said that if the insurance rejected it because it was not submitted in a timely manner, then I would be responsible for the full amount. They told me that they didn't receive insurance information from me, but I know that I had my insurance with me when I went there. I have received a few more bills with no insurance information on them, so I contacted my insurance company. They say that the claim was submitted in April of this year (after the 90 day "timely" deadline, and around the time that I sent in my insurance info in the mail) and so they sent something to the doctor's office asking for proof of timely submission. Are they responsible for filing a timely claim? Will I end up being responsible for the full amount? Do they have legitimate cause to send this to a collections agency?

Thanks

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depending on whether you have a PPO type insurance or not will make a difference. If a PPO and this doctor is a preferred provider, the contract between the insurance company and the provider would rule. If you are sure they had your insurance information, most PPO insurances would simply tell the provider they are out of luck and are not allowed to seek payment from the patient.

If this was not a PPO, you were liable for the bill regardless whether the insurance company was billed or not. You didn't pay it when you were made aware of the bill so yes, turning it over to a collection agency is a legitimate action.

[cbg]

Not just PPO's; any kind of managed care should be looked at.

But it's not the plan design that rules; it's whether or not the specific policy makes the doctor responsible for submitting claims. IF it does, then it's likely the doctor is out of luck (assuming that they definitely had your insurance information). IF it does not (and I am using emphasis deliberately) then you are going to have to pay the bill.

I assumed they billed my insurance and was awaiting a bill for whatever amount remained.

Regardless of plan design, always a bad idea. EVEN IF the doctor is responsible for submitting the claim, if you do not receive a bill or an explanation of benefits within a reasonable time after the visit, ASK. If the hold up is due to missing information that you can supply and you do not take any action, that can turn the tables and make you responsible after all.

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Thanks for the information, guys.

cbg, I have another question: Assuming the policy says the doctor is responsible for submitting claims, would I need to provide proof that they had my insurance information? I am sure they did, but I can't think of any way I would be able to prove it.

[cbg]

That's really going to be up to your insurance carrier. Once you read the policy and determine whether or not submitting claims is the doctor's responsibility (and for the moment assuming that it is) you'll want to call your insurance carrier and speak to a department that will be called Provider Relations or something on that order. They will be able to tell you what kind of proof they require, if any, and they will be the ones to talk to the doctor for you.

In fact, if you don't have a copy of the policy, it might be faster just to call them and ask what kind of responsibility for submissions the doctor has. You are entitled by law to a copy of the SPD (assuming that this is an employer sponsored plan) but it can take time to get one, and a phone call to the carrier might settle the matter faster.

[jk]

Thanks for the information, guys.

cbg, I have another question: Assuming the policy says the doctor is responsible for submitting claims, would I need to provide proof that they had my insurance information? I am sure they did, but I can't think of any way I would be able to prove it.

was this the first time you had ever visited that doctor? If not and you have proof they billed your insurance previously, they are going to have a hard time explaining how they lost your information.

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Yes, this was the first time.